APPEALS & GRIEVANCES FOR STATE, EDUCATION, LOCAL GOVERNMENT AND GROUP PLAN MEMBERS

Member Appeals and Grievance Procedures

In accordance with applicable laws, regulatory requirements, and established policies, GlobalHealth maintains effective processes to ensure timely response and resolution of member complaints.

Appeals and Grievances

An appeal is a request for reconsideration of a decision to deny services or payment of services (i.e., a denied benefit, claim or service). Appeals may be either standard or expedited. A standard appeal follows normal processing timeframes. An expedited appeal involves a request to appeal an adverse determination where the standard appeal process could seriously jeopardize the life or health of the member or the member's ability to regain maximum function. Expedited appeals apply only to decisions to deny services.

A grievance is an oral or written expression of dissatisfaction. Grievances may include quality of care concerns and/or quality of service issues such as office waiting times, physician behavior or adequacy of facilities. Regardless of the issue, GlobalHealth will attempt to resolve any complaint a member may have.

Timeframe for Resolving Appeals and Grievances

The following timeframe applies to each appeal and grievance:

Members must file their appeals within 180 days after the denial notification.

Standard appeals (denial of service) are resolved within 30 days of receipt by GlobalHealth.

Expedited appeals (denial of service) are resolved within 72 hours of receipt by GlobalHealth.

Standard appeals (denial of payment of a service already rendered) are resolved within 60 days of receipt by GlobalHealth.

Grievances are resolved within 30 days of receipt by GlobalHealth.

The timeframe for resolution may be extended upon mutual agreement by GlobalHealth and the member.

Levels of Review

An additional level of appeal through the Oklahoma Department of Insurance is available to members that have exhausted the internal appeals process with GlobalHealth. More information on the External Appeal process may be found at: https://www.ok.gov/oid/Consumers/External_Review_Process/

Who May File an Appeal or Grievance

A grievance or appeal can be filed by a member or someone else appointed by the member to file the appeal on his or her behalf. To appoint someone else as your representative, the member should provide the following:

A signed Appointment of Representative form (available from the GlobalHealth website)

A written statement from you that appoints the individual to act on your behalf.

For example: "I [member name] appoint [name of representative] to act as my personal representative in requesting an appeal from GlobalHealth regarding ________________________ (insert the type of denial or discontinuation of service and date)."

Include the member's GlobalHealth ID number.

Include the appointed representative's relationship to the member.

Include both the member and the appointed representative’s address and telephone number.

Both the member and the representative must sign and date the statement.

An expedited appeal may be filed by a physician on behalf of the member without submitting a member representative form.

How to Access the Appeals and Grievances Process

Contact GlobalHealth Customer Care at (877) 280-5600, or submit a written statement containing the following information:

Your name and address

Your GlobalHealth membership ID #

Provider of service

Copy of claims (if applicable)

A complete and accurate explanation of your appeal or grievance and the resolution you are seeking.

GlobalHealth will send a written acknowledgment of the receipt of your appeal or grievance and an explanation of the review procedure within five (5) calendar days of receipt.

APPEALS & GRIEVANCES FOR FEDERAL EMPLOYEES

Member Appeals and Grievance Procedures

In accordance with applicable laws, regulatory requirements, and established policies, GlobalHealth maintains effective processes to ensure timely response and resolution of member complaints.

Appeals and Grievances

An appeal is a request for reconsideration of a decision to deny services or payment of services (i.e., a denied benefit, claim or service). Appeals will follow the standard or expedited process. An expedited appeal is a request to change an adverse determination for urgent care where the standard appeal process could seriously jeopardize the life or health of the member or the member's ability to regain maximum function. Expedited appeals apply only to decisions to deny services.

A grievance is an oral or written expression of dissatisfaction. Grievances may consist of quality of care and/or quality of service issues, such as office waiting times, physician behavior or adequacy of facilities. GlobalHealth will attempt to resolve any complaint that the member might have. We encourage the informal resolution of complaints. However, if the complaint cannot be resolved in this manner, a more formal Member Grievance Procedure is available.

Timeframe for Resolving Appeals and Grievances

The following timeframe applies to each appeal and grievance:

Members must file their appeals within 180 days after the denial notification.

Standard appeals (denial of service) must be resolved within 30 days of receipt by GlobalHealth.

Expedited appeals (denial of service) must be resolved within 72 hours of receipt by GlobalHealth.

Standard appeals (denial of payment of a service already rendered) must be resolved within 30 days of receipt by GlobalHealth.

Grievances must be resolved within 30 days of receipt by GlobalHealth.

The Timeframe regarding GlobalHealth's resolution may be extended upon mutual agreement by the member.

Who May File an Appeal or a Grievance

A grievance or appeal can be filed by a member or someone else appointed by the member to file the appeal on his or her behalf. To appoint someone else as your representative, please provide the following:

Provide GlobalHealth a statement that appoints him/her to act on your behalf.

For example: "I [member name] appoint [name of representative] to act as my representative in requesting an appeal from GlobalHealth regarding ________________________ (insert the type of denial or discontinuation of service)."

Include the member's GlobalHealth Identification number.

Include the appointed representative's relationship to the member.

Include both the member and the appointed representative’s address and telephone number.

Both the member and the representative must sign and date the statement.

An expedited appeal may be filed by a physician on behalf of the member without submitting a member representative form.

How to Access the Appeals and Grievances Process

Contact GlobalHealth Customer Care at (877) 280-2989, or you may submit a written statement containing the following information:

Your name and address

Your GlobalHealth membership ID #

Provider of service

Copy of claims (if applicable)

A complete and accurate explanation of your appeal or grievance and the resolution you are seeking.

Forms are available upon request by calling GlobalHealth Customer Care at (405) 280-2989 (local), (877) 280-2989 (toll-free) or 711 (TTY/TDD/Voice), Monday-Friday, from 9:00AM-5:00PM. Submit your written statement to: GlobalHealth, Appeals and Grievances Department, P.O. Box 2393, Oklahoma City, Oklahoma, 73101-2393. GlobalHealth will send a written acknowledgment of the receipt of your appeal or grievance and an explanation of the review procedure within five (5) calendar days of receipt.

Levels of Review

An additional level of review through the Office of Personnel Management (OPM) is available to members that have exhausted the internal appeals process with GlobalHealth. Your request for external review must be submitted in writing within 3 months (90 days) after receipt of this notice to:

United States Office of Personnel Management

Healthcare and Insurance

Federal Employee Insurance Operations

Health Insurance 3

900 E Street, NW

Washington, DC 20415

For standard external reviews, a decision will be made within 60 days of receiving your request.

If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an expedited external review of our denial. If our decision was based on a determination that the service or treatment is experimental or investigational, you also may be entitled to file a request for expedited external review of our denial if your treating physician certifies in writing that the recommended or requested health care service or treatment would be significantly less effective if not promptly initiated. To request an expedited review, contact OPM’s Health Insurance 3 at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time.